Maine Behavioral Health Organization, Mental Health, Substance Abuse, Children & Adult Case Management, Outpatient Counseling, Med Management, Skowhegan, Augusta, Maine.

Personal Information

Referral Type:

Please check only the boxes for services that apply and are of interest.

Legal First Name:

Legal Last Name:

Name Preference:

Race (check all that apply):

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Ethnicity:

Primary Language:

Date of Birth:

Social Security Number:

Interpreter Needed?:

Type Needed:

Insurance Type:

Policy Number:

Group Number:

Physical Address:

City:

State:

Zip:

Mailing Address (if different from physical):

City:

State:

Zip:

Phone Number (for person being referred):

Email Address:

Phone Type:

Permission to leave message?:

Single Assessment Screening (Ages 0-20 Required)

Has the individual been referred in response to any of the following occurrences (select all that apply within the past (1) year)?:

Crisis Event

Hospitalization Related to Behavioral Health Risks

Arrest/Referral to Dept. of Corrections

Incarceration

Admission to Inpatient Psychiatric Care

Child Welfare Placement

Placement in Alternative School

Incident Endangering Self/Others at School

Not Applicable

Has a Single Assessment been completed?:

If yes, please provide the assessment date:

Have the results of the Single Assessment been reviewed with the Client and Family Team?:

Referral Information

Reason for Referral:

Dangerous variables (please include recent crisis/hospitalizations, incarcerations, violent or aggressive behavior, contagious medical conditions, criminal history, risk to self or others or other pertinent safety issues):

Mental Health Provider Names:

Other Information:

Guardian Information

Guardian Name:

Guardian Phone #:

Guardian Type:

Referral Contact Information

Referral Source Name/Organization:

Referral Address:

City:

State:

Zip:

Referral Phone:

Referral Cell Phone:

Referral Fax:

Referral Email Address:

Disclaimer & Verification

By entering the referral's name below, they certify that the information is true and complete to the best of their knowledge.

Referral's Signature:

Date:

If you're not a robot, what is 400 + 39?

List of additional agencies providing the same or similar services within 25 miles of our service area:
Agencies Districts 3-4-5 | Department of Health and Human Services

MBHO Referral Form

Referral Type: